Hip Arthroscopy Protocol - DOC by malj


									 Hip Arthroscopy Rehabilitation Protocol

             Michael B. Gerhardt, MD
Santa Monica Orthopaedic and Sports Medicine Group
         2020 Santa Monica Blvd. Suite 400
             Santa Monica, CA 90404
         Hip Arthroscopy Rehabilitation Protocol
                   Santa Monica Orthopaedic and Sports Medicine Group

This protocol is a generic outline of the postoperative management for patients undergoing hip
arthroscopy. Depending on the exact diagnosis and the procedures performed, the surgeon may
recommend variations of the therapy program. The therapist is encouraged to make
recommendations as issues arise and should not hesitate to contact the surgeon to discuss the
progress of these patients.

It is important to understand that rehabilitation after hip arthroscopy is very different than the
traditional therapy that has been employed for open hip surgeries, e.g. total joint replacement or
fracture stabilization. Traditionally physical therapy after open hip surgery employed the
principles of gait training, oftentimes with weightbearing restrictions and hip precautions. The
emphasis was largely on regaining the ability to perform activities of daily living.

The goals of patients undergoing hip arthroscopy are strikingly different. Oftentimes the patients
undergoing hip arthroscopy procedures are quite athletic and the goal is to return them to sports
as quickly as possible. Early weightbearing and range of motion exericises are emphasized.
Progressive strengthening programs are started almost immediately and cross training activities
are encouraged early in the rehabilitation process.

Ideally, a therapist-patient relationship will have already been formed as many of the patients
undergoing hip arthroscopy will have undergone a “prehab” program (See Prehab Handout).
Many of the same exercises used preoperatively will be employed in the postoperative period, but
in a slower and more progressive manner. The better conditioned the patient is preoperatively
will largely determine the rate at which the patient improves postoperatively.

The first step of the postoperative program will begin just like any other protocol with the initial
assessment and identification of the patient’s goals and expectations. The importance of the
therapist’s assessment cannot be overemphasized. We consider the physical therapy assessment
just as important as the medical assessment . The amount of time spent with the therapist by far
exceeds the amount of time spent with the physician and thus important details will often be
recognized that are not picked up by the surgeon. An ongoing dialogue with the physician is
encouraged and changes in the protocol can be adjusted as necessary depending on this

The goals of the patient should be clearly established and should be reviewed and adjusted
regularly. Unrealistic goals should be identified early and more realistic goals can be established.
Again, the diagnosis, the surgery performed and the preoperative activity level of the patient will
largely determine the ultimate goals – always remembering that the primary focus is to return
these people back to sports and training regimens as expeditiously and safely as possible.
Oftentimes in the elite athletes this will require “holding back the reigns” at times as these
patients tend to try to progress too rapidly and can actually inhibit their rehabilitative potential.
Again, this protocol is a general outline and can be accelerated or decelerated depending on each
individual situation. If any questions arise please contact Dr. Michael Gerhardt at (310) 829-
I.     Initial Phase
       Goals: Decrease soreness and swelling, gently increase range of motion to
       tolerance, inhibit further muscle atrophy
                 A. Day of surgery
                        1. Isometric glut sets, calf pumps
                        2. Cold therapy

                B. Postoperative days 1-7
                     1. Dressing change on postop day #1
                     2. Partial Weight Bearing with crutches or walker
                             a. Labral debridement – 5-7 days only
                             b. Osteoplasty (bone resection) – 2 weeks
                             c. Microfracture – 4 weeks
                     3. Postoperative exercises
                             a. Isometrics!!! Quad, gluts, hamstring,
                             b. Active assisted range of motion in all planes (do not
                                 push through painful endpoints)
                             c. Hip mobilization – straight plane distraction, inferior
                                 glides, posterior glides.
                             d. Closed chain bridging, weight shifts, balancing drills
                             e. Open chain standing abduction, adduction, flex/ext
                                 without resistance

II.    Intermediate Phase
       Goals: Regain and improve strength, regain normal joint kinematics
                A. Postoperative weeks 2 – 3
                     1. Normalize gait – eliminate limp!!
                     2. Continue to increase range of motion with gradual sustained end-
                         range stretches (still as pain tolerates).
                     3. Begin progressive resistive exercises as tolerated.
                             a. Closed chain single leg bridging
                             b. Open chain above knee resistive Theraband or pulley
                                 exercise in flexion, extension, adduction, abduction and
                                 hamstring curls as tolerated
                             c. Bike as tolerated
                             d. Pool exercises

III.   Advanced Phase
       Goals: Increase functional strength and endurance
                A. Postoperative weeks 4-6
                      1. Continue flexibility exercises
                      2. Continue progressive resistive strengthening exercises
                              a. Closed chain exercises as tolerated: multiplane strength
                                   exercises, hamstring curls, knee extensions

                B. Gradual progression of activities
                    1. Functional activities
                    2. Sport-specific activities
                           3. Return to sporting activity (with clearance from physician and
                              physical therapist)

Addendum – Distraction Mobilization Techniques

In athletes with painful hip disorders, distraction mobilization techniques can be very
effective both preoperatively and postoperatively. Distraction reduces the compressive
forces across the articular surfaces. This counterforce often provides significant relief to
an inflamed and irritated joint. Over time, these counter-reactive forces promote a
cartilage-healing environment in the hip which is an excellent adjunct to the traditional
hip range-of-motion and strengthening exercises. The following is a brief review of the
three distraction mobilization techniques for the hip:

       1.      Straight-plane distraction: The patient is in the supine position. The
               therapist grasps the lower leg above the ankle and applies a manual
               traction force. It may be necessary for an assistant to provide
               countertraction by stabilizing the torso. The traction vector can be applied
               with the hip in various degrees of flexion and abduction. Best results are
               accomplished if progressive and sustained distraction for 10-15 seconds is
               performed. The patient should be frequently reminded to remain relaxed
               so that joint distraction can be accomplished. 5 repetitions are
       2.      Inferior Glide distraction: The patient is supine with the hip and knee
               flexed 90 degrees. The therapist rests the patient’s lower leg on the
               therapist’s shoulder. A manual distraction force is applied to the proximal
               anterior thigh. This is best performed by interlocking both hands and then
               applying pressure, distracting in a distal direction. 5 repetitions are
       3.      Posterior Glide distraction: The patient is supine with the hip and knee
               flexed 90 degrees. The applied force is directed downward on the knee
               such that posterior translation of the femoral head is accomplished. The
               therapist should be positioned directly over the knee such that the
               therapist’s body weight can be used to gently apply the posteriorly
               directed force. 5 repetitions are recommended. (Note: This exercise
               should not be performed in patients with posterior instability.)

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